Rigi10™ Malleable Penile Prosthesis
Also Known As
Penile plication, Tunica albuginea plication, Corporoplasty (plication type), Penile straightening surgery (plication), Nesbit procedure (and modifications), 16-dot plication, Essed-Schroeder procedure, Penile tuck procedure
Definition
Plication procedures are a type of surgical intervention primarily used to correct penile curvature caused by Peyronie’s disease (PD) or, in some cases, congenital penile curvature.1–3 Peyronie’s disease is an acquired condition characterized by the formation of fibrous scar tissue, or plaques, within the tunica albuginea of the penis, leading to deformities such as bending, narrowing, or shortening of the penis, often accompanied by pain during erections and erectile dysfunction.1,4 The fundamental principle of plication surgery involves shortening the convex side of the penis—the side opposite the curvature—to straighten the penile shaft. This is typically achieved by placing a series of non-absorbable or long-lasting absorbable sutures into the tunica albuginea on the longer aspect of the penis, effectively cinching or tucking the tissue to counteract the bend caused by the plaque on the shorter, concave side.1,2,5 The goal of these procedures is not necessarily to achieve perfect straightness (zero degrees of curvature) but to render the penis functionally straight, generally defined as a residual curvature of 20 degrees or less, thereby allowing for satisfactory sexual intercourse.1,6
There are several variations of plication techniques, which can broadly be categorized into those that involve excision of a small piece of the tunica albuginea (excisional corporoplasty, like the original Nesbit procedure), those that involve making incisions into the tunica without removing tissue (incisional corporoplasty, such as the Heineke-Mikulicz based Yachia procedure), and those that only involve placing sutures to bunch or fold the tunica (plication-only techniques, like the 16-dot plication or Essed-Schroeder technique).1,3 Modern modifications, such as the Kiel Knots plication, focus on minimizing palpable sutures by burying the knots, while others, like the minimally invasive penoscrotal plication, aim to reduce surgical trauma by avoiding extensive degloving of the penis.1 Plication procedures are generally considered when the penile curvature is stable, typically for at least 6–12 months, and when the deformity significantly impairs sexual function.1,2 These procedures are often preferred for less complex curvatures (e.g., less than 60–90 degrees, depending on the specific technique and surgeon preference) in patients with good erectile function, with or without the use of oral medications or injections, and adequate penile length, as plication inherently causes some degree of penile shortening on the longer side of the curve.1,3 The purpose of plication is to restore penile straightness to a degree that allows for comfortable and functional sexual activity, improving the patient’s quality of life.1,2
Clinical Context
Plication procedures are clinically indicated for the surgical correction of penile curvature in adult males diagnosed with Peyronie’s disease or, less commonly, congenital penile curvature, where the deformity interferes with sexual intercourse or causes significant distress.1,2,3 Patient selection is a critical aspect for successful outcomes. Ideal candidates for plication surgery typically present with a stable penile curvature, meaning the deformity has not worsened for at least 6 to 12 months, and any acute phase symptoms like pain have resolved.1,2 The curvature should generally be less than 60–90 degrees, although some surgeons may perform plication for more severe curves in select cases.1,3 Crucially, patients should have adequate erectile function, either naturally or with the assistance of medical therapies (e.g., PDE5 inhibitors), as plication procedures do not address underlying erectile dysfunction and may even slightly compromise rigidity in some instances.1 Patients should also have sufficient penile length, as plication techniques inherently result in some degree of penile shortening, typically on the convex side of the penis, to achieve straightening.2,3 The expected amount of shortening is usually proportional to the degree of curvature being corrected. Therefore, individuals with pre-existing short penises or those who are very concerned about length loss may not be ideal candidates, or may be counseled towards alternative procedures like plaque incision/excision with grafting, though these carry their own set of risks, such as de novo erectile dysfunction.3 Plication is generally not recommended for patients with complex deformities such as an hourglass deformity or significant penile instability (hinge effect), as these may be better addressed with grafting procedures or the insertion of a penile prosthesis.3
The surgical procedure is usually performed on an outpatient basis under general or regional anesthesia.1 After inducing an artificial erection to precisely identify the point of maximum curvature, the surgeon makes an incision, often a circumcising one, to expose the tunica albuginea.1 Depending on the specific technique (e.g., Nesbit, 16-dot, Kiel Knots), sutures are placed on the convex side of the penis, opposite the plaque, to shorten this aspect and thereby straighten the penis.1 Some techniques involve excising or incising small portions of the tunica albuginea before placing sutures, while others rely solely on suture plication.3 The sutures are typically non-absorbable or long-lasting absorbable to maintain the correction over time.1 After the plication sutures are tied, another artificial erection is induced to confirm the adequacy of the correction.1
Expected outcomes for plication procedures are generally favorable, with high rates of achieving a functionally straight penis (often defined as less than 20 degrees of residual curvature), allowing for satisfactory sexual intercourse.1,2 Success rates in terms of penile straightening are often reported in the range of 80–95%.1,6 However, patients must be counseled about potential side effects, the most common being penile shortening, which can be a few centimeters depending on the initial curvature.2 Other potential side effects include palpable suture knots (though minimized with newer techniques), temporary or persistent penile pain, numbness or altered sensation in the glans or penile shaft, and a low risk of recurrent curvature or de novo erectile dysfunction.1 Recovery typically involves a period of abstinence from sexual activity for several weeks (usually around 6 weeks) to allow for healing.2 Most patients can return to non-strenuous daily activities within a few days.2 Swelling, bruising, and mild discomfort are common in the initial postoperative period.2